The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way?
A) Local response
B) Systemic response
C) Infectious response
D) Acute inflammatory response
Answer: B
The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse an
Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer?
A) Keep the pressure ulcer clean and dry.
B) Maintain protein intake of at least 1.25 g/kg/day.
C) Use a 10-mL syringe to irrigate the pressure ulcer.
D) Irrigate the pressure ulcer with hydrogen peroxide.
Answer:B
Adequate protein intake (between 1.25 an
An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient?
A) Dress it with an absorbent dressing for exudate.
B) Handle the wound gently and let it dry out to heal.
C) Debride the nonviable, eschar tissue to allow healing.
D) Use negative-pressure wound (vacuum) therapy to facilitate healing.
Answer: C
With a bl
A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection?
A) Increased platelet count
B) Increased blood urea nitrogen
C) Increased number of band neutrophils
D) Increased number of segmented myelocytes
Answer: C
The finding of an increased number of band neutrophils in circulation is called a shift to the left,
A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage?
A) Serous
B) Purulent
C) Fibrinous
D) Catarrhal
Answer: B
Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broke
The nurse assesses impaired skin integrity in this patient. How will the nurse document this?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
Answer: C
Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers
The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse?
A) Provide a light blanket.
B) Encourage a hot shower.
C) Monitor temperature every hour.
D) Turn up the thermostat in the patient's room.
Answer: A
Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a r
Which patient is most at risk for the development of a pressure ulcer?
A) An older patient who is septic, bedridden, and incontinent
B) An obese woman with leukemia who is receiving chemotherapy
C) A middle-aged thin man in a halo cast after a motor vehicle accident
D) An adult with type 1 diabetes mellitus admitted in diabe
A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)?
A) Take the antibiotic until the wound feels better.
B)Take the analgesic every day to promote adequate rest for healing.
C) Be sure to wash hands after changing the dressing to avoid infection.
D) Take in more fluid, protein, and vitamins C, B, and A to
The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse?
A) Notify the health care provider.
B) Document the fistula formation.
C) Assess the patient and vaginal drainage.
D) Have the UAP apply a dressing to the vagina.
Answer: C
With Crohn's disease, a fistula may have formed between the bowel and the vagina.
After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care?
A) Reposition every 2 hours.
B) Measure the size of the reddened area.
C) Massage the area to increase blood flow.
D) Evaluate the area later to see if it is better.
Answer: A
The most important thing to do for this patient is to prevent deterioration of
The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection?
A) Fever and chills
B) Increased blood pressure
C) Increased respiratory rate
D) General malaise and fatigue
Answer: D
An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal imm
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment?
A)Frequent examination of the character and quantity of exudate
B) Monitoring for signs and symptoms of local or systemic infections
C) Assessment of the patient's circulation distal to the location of the dressing
D) Assessment of the range of motion of
A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be?
A) Adhesion
B) Contractions
C) Keloid formation
D) Excess granulation tissue
Answer: D
Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form
A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury?
A) Warm, moist heat and massage
B) Rest, ice, compression, and elevation
C) Antipyretic and antibiotic drug therapy
D) Active movement and exercise to prevent stiffness
Answer: B
Rest, ice, compression, and elevation (RICE) is a key concept in treating so
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102�F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication?
A) Pain level
B) Intake and output
C) Oxygen saturation
D) Level of consciousness
Answer: B
Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be
To which patient should the nurse plan to administer round-the-clock antipyretic drugs?
A) A 76-yr-old patient with bacterial meningitis and a temperature of 104.2�F
B) An 82-yr-old patient after hip replacement surgery and a temperature of 100.4�F
C) A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6�F
D) A 59-yr-o
The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process?
A) The wound will be stapled together until it heals.
B) The healing will contract the area to close the wound.
C) The wound will be left open and heal from the edges inward.
D) The wound will be sutured after the current infection is controlled.
Answer:
A patient with pneumonia has a fever of 103�F. What nursing actions will assist in managing the patient's febrile state?
A) Administer aspirin on a scheduled basis around the clock.
B) Provide acetaminophen every 4 hours to maintain consistent blood levels.
C) Administer acetaminophen when the patient's oral temperature exceeds 103.5�F.
D) Provide drug interventions if comp
When the nurse changes the dressing and documents that there is serosanguineous drainage, which type of drainage did she see on the dressing? (Images from Potter PA, Perry AG: Fundamentals of nursing, ed 7, St Louis, 2009, Mosby.)
Image C
Serosanguineous drainage is frequently seen postoperatively and is composed of RBCs and serous fluid so it is a semiclear pink drainage. Serous drainage is a thin, watery drainage. Hemorrhagic drainage is bloody drainage. Purulent drainage consist
When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective?
A) White blood cell (WBC) count of 8000/�L; temperature of 101 F
B) White blood cell (WBC) count of 4000/�L; temperature of 100 F
C) White blood cell (WBC) count of 8500/�L; temperature of 98.4 F
D) White blood cell (WBC) count of 16,500/�L; temperature o
A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing?
A) Apple
B) Custard
C) Popsicle
D) Potato chips
Answer: B
Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a sm